Provider Demographics
NPI:1831225952
Name:KELISHADI, SHAHROOZ SEAN (MD)
Entity type:Individual
Prefix:
First Name:SHAHROOZ
Middle Name:SEAN
Last Name:KELISHADI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 SUPERIOR AVE
Mailing Address - Street 2:STE 340
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3609
Mailing Address - Country:US
Mailing Address - Phone:949-515-7874
Mailing Address - Fax:
Practice Address - Street 1:500 SUPERIOR AVE
Practice Address - Street 2:STE 340
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3609
Practice Address - Country:US
Practice Address - Phone:949-515-7874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-25
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA127984208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery